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Sep 29 03 06: 56a Charity Miles (20Q1 533-2650 p• 1 AIIite h 17759 Buttercup Circle, Sonora, CA 95370 .,,, Phone: 209-532-7320; Fax: 209-533-2650 California Contractor 623541 A-Haz aRtech@getrocket.com getrocket.com MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Costco#658 Tracy Date of Testing/Servicing: September 16,2003 Facility Address: 3250 W. Grant Line Road,Tracy CA Facility Contact Person: Ser. Sta. Supervisor; Leo LIA: San Joaquin; Steven L1A Phone: Make/Model of Monitoring System: Veeder-Root TLS-350 B. Inventory of Equipment Tested/Certified: C.Ikcrk the appropriate boxes to indicate specific equipment ins ect,&,,.,,iced: Tana ID:Regular I Tank Tank ID:Regular 2 Tank 0 In-Tank Gauging Probe. Model.Mag 1 ®In-Tank Gauging Probe, Model:Mag I ®Annular Space or Vault Sensor. Model:Sin)e-Float Brine 0 Annular Space or Vault Sensor. Model:Single-Float Brine N Piping Sump Sensor(s). Model:Discriminating Sensor 0 Piping Sump Sensor(s). Model:Discriminating Sensor Fill Sump Sensor(s). Model:Discriminating Sensor ®Fill Sump Sensor(s). Model:Discriminating Sensor Mechanical Line Leak Detector. Model:Red Jacket 0 Mechanical Line Leak Detector. Model:Red Jacket ❑Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: 19 Tank Overfill/High-Level Sensor. Modcl:Viceder-Root Audible 10 Tank Overfill/High-L.evcl Sensor. Model:Veeder-Root Audible ❑Other ❑Other Tank ID:Premium Tank Tank ID: In-Tank Gauging Probc. Model:Mag 1 U In-Tank Gauging,Probe. Model: Annular Space or Vault Sensor. Model:Single-Float Brine ❑Annular Space or Vault Sensor. Model; Piping Sump Sensor(s). Model:Discriminating Sensor ❑Piping Sump Sensor(s). Model: ®Fill Sump Sensor(s). Model:Discriminating Sensor ❑Fill Sump Sensor(s). Model: ®Mechanical Line Lcalt Detector. Model.Vaporlcss D Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector- Model: 21 Tank Overfill/High-Level Sensor. Model:Veeder-Root Audible ❑Tank Overfill/High-Level Sensor. Model: ❑Other ❑Other Dispenser ID: 1&2 Z Sump:0Dry❑Water[]Product Dispenser ID:3&4® Sump:NDryWater ❑ []Product 19 Dispenser Containment Sensor(s). Model:Non-Discriminating U Dispenser Containment Sensor(s). Model:Non-Discriminating ®Shear Valve(s) (Functional test) ®Shear Valve(s) (Functional test) ❑Dis2qnser Containment Float(s)and Chain(s). ❑Dis2nscr Containment Floats and Chaff s . Dispenser ID:5&6®Sump:EDry❑Water❑Product Dispenser ID:7&8® Sump:MDry❑Water[]Product ®Dispenser Containment Sensor(s). Model:Non-Discriminating ®Dispenser Containment Sensor(s). Model:Non-Discriminating ®Shear Valves) (Functional test) 0 Shear Valve(s) (Functional test) ®Dispenser Containment Float(s)and Chains . ❑Dispenser Containment Floats and Chain s). Dispenser ID:9&10 9 Sump:®Dry[]Water❑Product Dispenser ID: l I&12 0 Sump:MDry❑Watcr[I Product ED Dispenser Containment Sensor(s). Model:Non-Discriminating ®Dispenser Containment Sensor(s). Model:Nan-Discriminating N Shear Valve(s) (Functional test) Z Shear Valve(s) (Functional test) ❑Dispenser Containment FloatW and Chain(s). ❑Disinnser Containment Float(s)and Chains . Dispenser ID: ❑Sump:❑Dry❑Water❑Product Dispenser 1D: ❑Sump. ❑ El Dispenser C nrtainment Scnsor(s). Model: L]Dispenser ContainmentSensor(s). o el: ❑Product ❑Shear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) ❑Dis22nser Containment Floats and Chain(s). ❑Dis enser Containment Float(s)and Chain{s . C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'guidelines. Attached to this Certification is information(e.g.manufacturers,checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): M System set-up ED Alarm history report Technician: A41 ig-pe*4 Mike Dotten,California Contractor 623541 A-Haz Certification: Weeder-Root:341-32-6743; Level 3.